An update from Carol Povey at the National Autistic Society regarding Mendip House

Last week, we released a statement regarding the abuse at Mendip House. At the time, we said we had approached NAS for an update on what they had done to learn from events and make sure they could not happen again. Below is Carol Povey’s response in full.


Dear Tracy,

Many thanks for your e mail following the Safeguarding Adults review into the horrific events which happened in Mendip House in 2016.

We had correspondence in August 16, and in November 2016, we closed Mendip House. I think, when we spoke, we had taken that decision, and were in the process of working with families and the people who were living there, to find alternative accommodation and support which would meet their needs.

We want to reiterate how appalled we were by the cruel behaviour towards the people we supported at Mendip House by some staff there. And we apologise without reservation for the failures at Mendip House and for not spotting them and putting them right as quickly as we should have. We have since done all we can to ensure this cannot happen again.

The timeline can be difficult to follow, because the Safeguarding Adults Report into Mendip House draws on a range of minutes and reports from other enquiries by Somerset County Council, the Care Quality Commission and the NAS, rather than being based on a single, stand-alone investigation, but the following gives an account of what happened and when:

• In May 2016, a member of staff alerted us and the CQC to abusive behaviour by some members of staff towards the people we supported at Mendip House. These are the extremely distressing accounts of abuse detailed in the SAR report.
• In May 2016, we immediately made sure everyone living at Mendip House was safe and properly supported by staff who knew them and their needs well. The staff responsible for the abuse were immediately suspended and disciplinary investigation started, which resulted in their dismissal.
• In May 2016, we undertook a full review of all previous safeguarding alerts and supplied this to the CQC. The CQC inspected Mendip House. Somerset County Council, as the agency responsible for safeguarding in the area, started a safeguarding inquiry process, including placing a team at Somerset Court for several months.
• In June 2016, we calculated then repaid the money taken from the people who lived at Mendip House by staff who had been getting them to pay for their meals.
• In July 2016, we took the difficult decision to close Mendip House because of the depth of the problems we had discovered there.
• In August 2016, the CQC published their report, which found the service inadequate in all areas. We apologised publicly and acknowledged that we’d ‘failed badly’ at Mendip House
• In early November 2016, Mendip House closed, after the last of the people who had been living there moved to their new home.
• In March 2017 the Somerset Adult Safeguarding Board started the Safeguarding Adults Review (SAR). We worked with the review author, council staff, the Care Quality Commission, the Clinical Commissioning Group and the police to contribute to lessons learnt about what went wrong at Mendip House.
• On 8 February 2018 The Safeguarding Adults Board published the SAR report.

From when the situation at Mendip House first came fully to light in early May 2016, we’ve worked to understand what went wrong and introduce the necessary changes to stop the combination of cruel and unprofessional staff practice and a failure to quickly spot this and put it right.

We don’t believe that what happened at Mendip House represents the experience of the people we support in our other services, nor the attitudes or practice of our staff. Our adult social care services are rated above the national average. But, we need to make sure that we do everything we can to prevent any abusive behaviour like this happening again. In my last letter to you, I said we would be reviewing all our policies and procedures. We have done this and made the following changes to the way we work. We have:
• Put in an independent whistleblowing line so that staff can confidently report any concerns. We’ve seen a significant increase of 14% in staff awareness of how to whistleblow in our independent staff survey, putting us 7% ahead of similar care providers. We will continue to promote this to staff.
• Increased proactive contact with family members of people we support so that we can pick up on even minor concerns that otherwise
• Started more in-depth data analysis so that we look at data on safeguarding, staff retention, complaints, disciplinaries and other indicators in the round and report on trends in services so we can pick up on minor changes and intervene early if there are any concerns.
• Introduced a new quality assurance process – we will commission an independent evaluation of this after 6 months to be sure that it is working
• Co-opted independent, experienced safeguarding professionals (including a Local Authority ex-director of Adult Services) onto our Services Quality and Development committee
• Begun the process of creating an independent safeguarding panel, in addition to our Services Quality and Development committee, to make sure that all safeguarding issues get properly scrutinised and dealt with
• Introduced a ‘lessons from Mendip House workshop’ for frontline staff and managers from Autumn 2016. It shows what can go wrong and brings starkly to life the necessity of all staff and managers taking responsibility and acting when they see practice deteriorating as it did at Mendip.
• Strengthened our quality improvement teams in each area of the country– these now include autism practice facilitators, positive behaviour support co-ordinators, learning and development staff, behaviour support and health and safety trainers).
• Improved our culture and worked to embed our values in our workforce, for example through values-based recruitment and reflective supervision. Although this will take time, we’ve already seen in our Oct 2017 independent staff survey a 13% increase year-on-year in those agreeing that: ‘Our charity has strong values which are put into practice’.
• Audited all our policies so that they are clearer and are more closely monitored.
• Improved investigations training so that managers are better able to conduct good quality investigations if there are any concerns about our practice.

We have subscribed to the Driving up Quality Initiative, and to STOMP, and these are both integrated into our way of working. Throughout this time, we have been working closely with the Somerset Adult Safeguarding board to ensure we have learnt from these terrible events, and can make sure they never happened again, not only in NAS services, but across the social care sector. We will be participating in the Somerset Adult safeguarding conference to share what we’ve learnt, and will continue to talk about both what we got wrong, and what we’ve done to change things.

Contrary to some of the reports in the media, we have not covered up anything that happened at Mendip House, or our actions in response to those events.

When we last spoke, I said our Chief Executive, Mark Lever, was hoping to hold a roundtable to look at how we, and other organisations, can and should respond to when things go wrong to ensure events done repeat themselves. This has taken longer that we had hoped, but we still intend doing this, and will invite representatives from Learning Disability England.

I’d also like to reiterate the offer I made in August 2016. I am more than happy to join you in any forum which can enable us, as a group of organisations providing services to people with learning disabilities and/ or autism to use our learning to improve services or our responses to poor practice and other service failings.

With best regards

Carol Povey
Director of the Centre for Autism
The National Autistic Society

We need a culture change!

LDE’s Tracy Hammond reflects on recent events

Over the last week or so, the Learning Disability Care and Support sector has not been covered in glory. The tragic and avoidable death of Richard Handley has hit the news, the abuse at Mendip House has come under the spotlight again, and events in West Sussex continue to be of public interest. In addition, the Charity Sector as a whole is facing public anger regarding the dreadful abuse of vulnerable people by Oxfam workers, and the Charity Commission’s ability to regulate is being questioned.
It seems the sector doesn’t need programmes like Silent Witness to damage public perception of us; we’re managing this all on our own!

How can this happen? How can truth sometimes be as awful as fiction, and how can there be an environment where it becomes usual to accept or perpetrate abuse, or not to notice, or care sufficiently to put an end to neglect? I can almost see any reader bracing themselves for my next sentence which will, they expect, be about money. Except it’s not. Money is not the problem, and it’s certainly not the whole answer! Frankly, we managed to get it spectacularly wrong when there was more money in the system.

We live in a world where we commission accommodation in units, where people have packages of support, and where we account largely for time spent in cost per hour. After Winterbourne, we did a lot of navel gazing and produced a great many policies and a few reports, and yet abuse and neglect still happen. Sadly, this will continue until we stop de-humanising people. We do this through our language, when statistic-based management strategies blind us to the plight of individuals caught up in a poor service, and through the adoption of practices which turn people into packages. Indeed, NAS’s own response to events at Mendip House said, ‘People were not at the centre of what we were doing’, and Richard Handley died despite having a hospital passport, being on the GP’s learning disability register, and having some annual health checks.

Greater independence or self-direction of support is often and rightly seen as the holy grail of learning disability services but what about the journey? My husband and I have recently moved to another part of the country, and idioms are slightly different. As a good London boy, my husband will still greet someone by saying ‘alright’. However, here, rather than a perfunctory greeting, he often gets a full and sometimes frank appraisal of someone’s “alrightness”. When we receive this full reply, no one has ever told us about whether they have made their own bed or improved their ironing skills. They tell us how they are feeling, about the impact of their relationships, and generally give us an update on their happiness. None of these things are effectively recorded in outcomes monitoring sheets, and tenders to encompass such intangibles are difficult to write, and rarely attempted. Yet these are the things that matter.

A short while ago, when the Silent Witness story involving people with learning disabilities was being aired and discussed, I invited people to provide examples of good support and to celebrate the good in the sector. At the time, I wasn’t being terribly strategic; I just wanted to counter some of the negativity around. We got some great stories, and posts had warmth and humanity.
However, today, may be such actions are strategic; I’m not for a moment calling on us to forget that dreadful abuse can and does happen, but if we truly want change, we must admit that calling for something to stop is insufficient. We need to deliberately, corporately and individually strive for a positive culture change, and to understand how to embed this. We need to change our language into one that talks about people rather than bed-spaces or units, put happiness at the centre of our support requirements, celebrate the good, measure the right things, and be utterly unaccepting of anything that gets in the way of the best support possible.

Last week, I was discussing LDE’s Driving Up Quality work and thinking about how this can support people to give and receive great support. We discussed how its lack of rigidity is its strength, and I heard some great stories of how organisations had used it to sit down with people, work out where they could improve things and then take action. Recently, I had the privilege of shortlisting the Driving Up Quality awards. The best entries begun with a name and ended with details of how someone’s life had changed.

Richard Handley – a statement

Richard Handley died of complications from constipation in November 2012, and his inquest concluded last week.

Supported living is defined as persons with disabilities living where and with whom they want, for as long as they want, with the ongoing support needed to sustain that choice.” No part of this definition implies that someone’s care should be of a lower standard than when living in a registered home. Yet, this reduction in care is what happened to Richard Handley, and is something that undoubtedly contributed to his death.

There were so many opportunities to save Richard, and yet these were tragically missed. So much of Richard’s story appears to be about communication, and aside from his loving family, people not really knowing him. For example, his medication was changed to include one with a side-effect of constipation, his diet and bowel movements were not monitored as needed for his well-being, and his key worker was unaware of his bowel condition. Once in hospital, monitoring was not effective.

That someone could die from constipation in this day and age is upsetting and difficult to comprehend. That the coroner said “…Without the diligence and persistence of (the family), many of the reviews into Richard’s death would not have occurred…” is deeply troubling.

LDE will continue to work with all sections of the learning disability community to ensure that people get the support they want and need.

For support to be effective, it has to be delivered by people who know the person well, and have the information they need.

We know that the agencies involved have already learned from Richard’s appalling death, but we hope that anyone offering care and support is asking themselves, “Could this happen on my watch?”.

Mendip House and NAS

The Mendip House safeguarding report which has just been issued outlines in detail the abuse which occurred and makes distressing reading. There can be absolutely no excuse for the horrific events which took place there.
In September 2016 LDE released a statement about the poor care and support that had taken place at Mendip House. As the National Autistic Society (NAS) are our members we were extremely concerned about what had happened and wrote to them with our concerns. They replied to our letter and explained what they were doing to address the abuse that happened.
Actions included closing Mendip House, this has now been done, and addressing concerns about issues not coming to the attention of the leadership team quickly enough. We were reassured that NAS was dealing with the situation with apparent openness and vigour.
We have written to NAS again asking them to update us on their actions and to ensure their policies and practices now fully safeguard the people they have the privilege to support. We will share their response on this site once received.

Guest Blog from KeyRing A ‘home for life’

I’m, ahem, late 30’s and I cannot even begin to think that this beautiful house in which I am lucky enough to live could be a ‘home for life’. I’d like a bigger garden, windows in the bathrooms and a utility room to name but a few of my requirements.
The term is completely alien to me so why do I hear it so often when discussing the needs of people with a learning disability? I fear that this notion is one that was part of a movement towards people having a say about where they live. It had its merits but it’s time now to leave it in the past.
People are often limited by the expectations of those around them. It is up to us to help them aspire to exceed those expectations. People need to be taught about the real options that are available to them and be encouraged to explore them. Flux is part of life and life is for the living. Telling an individual that their Shared Living accommodation is their ‘home for life’ is self limiting. I went through numerous tenancies and, let me tell you, I’ve experienced a fair few disagreements, toilet roll hiding being a common outcome of many of these. If someone had told me that the inconsiderate, up all night partying, boys that I shared with in my early 20’s were in my home for life, you’d better believe that I would be displaying ‘behaviour that challenges’.
Not only that, but surely the ‘home for life’ option is the most costly to the public purse? It’s a bit like a parent never giving any freedom or life skills to their offspring. They are likely to either completely rebel or they will just become so reliant on the parent that they never move on. As providers we have the same duty of care to guide people, to give them the life skills that they need and, most of all, let them go when it is time.

written by: Charlie Crabtree, Development Manager
Charlie has been working as a Development Manager at KeyRing for the past 8 years. She loves asking questions that challenge people’s preconceived notions of what individuals can achieve. She is partial to Netflix as well as regularly attending the gym and is an active member of her local Timebank

We’re recruiting for a Chief Executive!

Learning Disability England are recruiting a new Chief Executive to build on the strong foundations of this new organisation and deliver our vision for the future.
We are seeking a visionary and inspirational leader and coach who is values driven and supports others to lead. With direct experience of the learning disability sector and a track record of developing successful strategies with multiple stakeholders our new Chief Executive will be a strong facilitator, communicator and fundraiser, confident in representing the organisation and with experience of enabling staff to work effectively. Adept at corporate governance, the Chief Executive will be confident working within a complex governance environment and crucially will be collaborative and ‘low ego’; motivated primarily by others succeeding over achieving their own personal agenda.
• Location flexible with regular travel throughout England
• c. £50,000 per annum
• working days flexible
• Permanent
• Closing Date: 9am 28th February 2018
• Interview Dates: 14th and 15th March 2018

Learning Disability England is the first membership organisation that brings together people with learning disabilities, families and friends, professionals and organisations, by working together we can achieve more, by sharing ideas and working with our members, their expertise helps us make services stronger and society fairer. We take people’s voices and make them louder. We do not speak for people with learning disabilities because we know that they can speak for themselves, and doing this will change the way society sees them.

To discuss further please contact Karyn Kirkpatrick, LDE Chair on 07989 983829

To apply please send your CV and covering letter to LDE

c/o Choice Support
100 Westminster Bridge Road
FAO Debbie Palmer

Single Equality Policy
Personal Details Form
Job Description-and-Person Specification

Understanding the key requirements of the GDPR

10.00 – 11.00, 2nd February 2018

Our next free webinar for LDE members is being presented by Helen Cookson. This is an hour-long introduction to GDPR with a particular focus on understanding the key requirements and demystifying the core principles of data protection.  Helen will look at the steps which organisations are expected to be taking to prepare for the implementation of the GDPR in May 2018 and help you understand some of the common pitfalls so that you can focus your action plan to most effect.

Helen is a senior associate in Trowers & Hamlins LLP’ Privacy and Information Law group, and also works within our Employment Team.   Helen advises public, third and private sector clients with a particular focus on social care clients and advises on a range of data protection, privacy, and freedom of information issues with a particular focus on the issues which most often arise in relation to employees, including subject access requests and data sharing.  She is a very experienced seminar speaker and often provides training on data protection issues.  In particular, she is one of the team leading on helping our clients gear up for the GDPR with the aim of taking a practical approach to the new law.

The 2018 edition of the Legal 500 (North West Employment) notes that she “is adept at advising on data protection issues linked to employment”.


Philip Hammond causes storm with remarks about disabled workers

LDE is very disappointed that Philip Hammonds comments give a very misleading picture about the access which disabled people have to the labour market and about the massive contribution which they make when they are given the opportunity to be economically active.

Figures suggest that just 6% of adults with a learning disability known to their local authority in England are in paid work (HSCIC 2015).  This amounts to just shy of 7,500 people.  Figures also suggest that a total of 17% of adults with learning disabilities aged between 16 and 64 are employed.  The difference between these figures shows how few people receive local authority support.

We believe that government policy is failing people with learning disabilities and respectfully suggest that rather than charging people who have been so dramatically failed with the country’s woes, he should dig deeper, look to really understand the issues and refrain from sweeping statements which blame disempowered people for policy failings.

Sleep-Ins Update

LDE wrote a plain English briefing on sleep-ins and National Minimum Wage back in July. You can read that briefing here.

The government has just made a new announcement about sleep-ins and National Minimum Wage. We think it is important to share this news with our members.

Read more  “Sleep-Ins Update”